RC-17-2776Nem )1- AS-- e- -
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1
Project Address
5 NE 107 Street
Miami Shores, FL 33161-7029
Miami Shores Village
10050 N.E. 2nd Avenue NE
Miami Shores, FL 33138-0000
Phone: (305)795-2204
Permit
Permit NO. RC -11-17-2776
Permit Type: Residential Construction
Work Classification: Addition/Alteration
Permit Status: APPROVED
Issue Date: 11/27/2017
Expiration: 05/26/2018
Parcel Number
1121360070330
Block: Lot:
Applicant
EAST WEST PROPERTIES HOLE
Owner Information
Address
EAST WEST PROPERTIES HOLDINGS 3900 NW 2 Avenue
- - - MIAMI FL 33127-
3900 NW 2 Avenue
MIAMI FL 33127-
Phone
Cell
Contractor(s) Phone Cell Phone
BIRD PLUMBING CORPORATION (305)219-3448
Valuation:
Total Sq Feet:
$ 10,500.00
0
Approved: In Review
Comments:
Date Approved:: In Review
Date Denied:
Type of Construction: CHANGE 17 WINDOWS AND 1 DOC
Stories: 1
Front Setback:
Left Setback:
Bedrooms: 4
Plans Submitted: Yes
Certificate Date:
Bond Return :
Occupancy: Single Family
Exterior:
Rear Setback:
Right Setback:
Bathrooms: 3
Certificate Status:
Additional Info:
Classification: Residential
Fees Due
CCF
DBPR Fee
DCA Fee
Education Surcharge
Permit Fee
Scanning Fee
Technology Fee
Total:
Amount
$6.60
$4.73
$3.15
$2.20
$315.00
$9.00
$8.80
$349.48
Pay Date Pay Type
Invoice # RC -11-17-65724
11/27/2017 Credit Card
11/21/2017 Credit Card
Amt Paid Amt Due
$ 299.48 $ 50.00
$ 50.00 $ 0.00
Available Inspections:
Inspection Type:
Drywall
Miscellaneous
Window Door Attachment
Tie Beam
Final
Framing
Insulation
Final PE Certification
Truss Insp
Foundation
Window and Door Buck
Columns
Fill Cells Columns
Wire Lathe
Review Building
Review Mechanical
Declaration of Use
F. Termite Letter
F. Elevation Certificate
Review Planning
Review Structural
Review Electrical
Review Plumbing
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In
accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are
required for ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work.
OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction and zoning. Futherm.re, authorize the above-nar. =&ctrnfractor to do the work stated.
November 27, 2017
Authorized Si4 plicant / Contractor / Agent
Building Department Copy
Date
November 27, 2017
1
BUILDING
PER IT APPLICATION
IVIIdI I II Jill/ICJ V IIIdge
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
Master Permit No.
Sub Permit No.
BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF
CONTRACTOR
JOB ADDRESS: 5 PJB.. 1 c7--1 S -1 -
City: Miami Shores County: Miami Dade
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone:
RECEIVE
NOW 1 1011^
FBC zay
❑ EXTENSION ❑ RENEWAL
❑ CANCELLATION
❑ SHOP
DRAWINGS
Zip: 3
BFE: FFE:
OWNER: Name (Fee Simple Titleholder): C Pro per4i 4 _f Phone#: LL�T ..
Address: O O (V
City: State: FL Zip:
Tenant/Lessee Name: Phone#: S -(, q 3�
Email: ed r-rrn o• -,d 1 c i c.) of d o— f Cr -o,, , 4c1 (p
CONTRACTOR: Company Name: (Y)C ( (i C#.c 1-J Phone#. - i�34'42,
Address: 2-704- c( 1261
City:
Qualifier Name:
State:
Pv\ 1rY�C.� ,evlG-{-I-•C e
Zip: 3a -o08
Phone#:
State Certification or Registration #: C. G 01 (o I 0 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ 15 oo 0 Square/Linear Footage of Work: 1 in 0 O
Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition
Description of Work: Com'
Vvl cl��,-S / clOc» .0 Q p@" .
Specify color of color thru tile:
Submittal Fee $
Scanning Fee $ a
Technology Fee $
Structural Reviews $
Permit Fee $ 3( • o°
Radon Fee$ ��. (S
CCF $ CO/CC $
DBPR $ `-4 • Notary $
Training/Education Fee $ Double Fee $
Bond $
TOTAL FEE NOW DUES 2''7 . 'TCJ
Bonding Company's Name (if applicable)
BondingiCompany's Address
City State Zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City State Zip
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating
construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS,
FURNACES, BOILERS, HEATERS, TANKS, AIR CONDITIONERS, ETC
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all
applicable laws regulating construction and zoning.
"WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY
RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING
YOUR NOTICE OF COMMENCEMENT."
Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature
OWNER or AGENT
The foregoing instrument was acknowledged before me this
�-
dayof(D✓ •
Gc r•a-„A L e.i dFt(hiSi
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
, 20
I"7
, by
Sign:
Print:
Seal:
q61--rta
to
as
em; Qr.
Signature 6/12,,hati
CONTRACTOR
The foregoing instrument was acknowledged before me this
sA”—day of —fc� �/ , 20 1•—) , by
,P'c""t j i'—'e1Cr440r,wgo is sopa y nown o
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign: +N' a p),0, -,,,u L
1
RONNI-ANN BLANK
MY COMMISSION #FFfillifft4
'•'�ovFcF: EXPIRES October 1, 2018
ow) 398-01$3 Floridallo Service.com
********************************
APPROVED BY
'. : RONNI ANN BLANK
r.
MY COMMISSION #FF158014
EXPIRES October 1, 2018
(407) 398-0153 FloridallotaryService.com
** * * *******************************************************************
Plans Examiner Zoning
Structural Review
Clerk
Miami Shores Viiiage
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Notice to Owner — Workers' Compensation Insurance Exemption
Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05
allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to
obtaining a building permit. Pursuant to the Florida Division of Workers' Compensation Employer Facts Brochure:
An employer in the construction industry who employs one or more part-time or full-time
employees, including the owner, must obtain workers' compensation coverage. Corporate officers
or members of a limited liability company (LLC) in the construction industry may elect to be
exempt if:
1. The officer owns at least 10 percent of the stock of the corporation, or in the case of
an LLC, a statement attesting to the minimum 10 percent ownership;
2. The officer is listed as an officer of the corporation in the records of the Florida
Department of State, Division of Corporations; and
3. The corporation is registered and listed as active with the Florida Department of
State, Division of Corporations.
No more than three corporate officers per corporation or limited liability company members are
allowed to be exempt. Construction exemptions are valid for a period of two years or until a
voluntary revocation is filed or the exemption is revoked by the Division.
Your contractor is requesting a permit under this workers' compensation exemption and has acknowledge that he or she will not use
day labor, part-time employees or subcontractors for your project. The contractor has provided an affidavit stating that he or she will
be the only person allowed to work on your project. In these circumstances, Miami Shores Village does not require verification of
workers' compensation insurance coverage from the contractor's company for day labor, part-time employees or subcontractors.
BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
County of Miami -Dade
EG%' -no -J
The forgoing was acknowledge before me this a- `s day of Ni Oma/
G r-eNo-•J i c) t.! cl 0--
By
—By t '-1( Gr" Ne. -a who is : sonally k
Notary:
SEAL:
(1)0,4-kiti
as identification.
,201-.
to me or has produced
MARLIN CONTRACTORS, INC
27084 29TH RD UNIT A
BRANFORD, FL 32008
ALFRED MATTERN, CGC 012610
Date: Na
State of f L_ . County of t ct;Cae .
Before me this day personally appeared ,c\.F - ci 'Rho, being duly
sworn, deposes and says:
That he or she will be the only person working on the project located at:
5 1..E _ -�--� c> -Y-.; S►'-u�-cJ ,'Z_.
Contractor Signature
Sworn to (or affirmed) and subscribed before me this D. ''ay of N-10./ .
20 f , by' CI—CC{ .
331 1
C;rsonallOR Produced Identification Type of
Identification Produced
Ron n 1114 6141 -AA Print, Type or Stamp Name of Notary
41Y,°4:: RONNI ANN BLANK
(�' MY COMMISSION #FF158014
\
;�' Vo :'
,,�d!,= EXPIRES October 1, 2018
(407) 3Ci8-0153 FlorldallotaryService.com
11/21/2017
Property Search Application - Miami -Dade County
flCE OF THE PROPERTV APPRASER
Summary Report
Property Information
Folio:
11-2136-007-0330
Property Address:
5 NE 107 ST
Miami Shores, FL 33161-7029
Owner
EAST WEST PROPERTIES
HOLDINGS LLC
Mailing Address
3900 NW 2 AVE
MIAMI, FL 33127 USA
PA Primary Zone
1000 SGL FAMILY - 2101-2300 SQ
Primary Land Use
0101 RESIDENTIAL - SINGLE
FAMILY: 1 UNIT
Beds / Baths / Half
3/2/0
Floors
1
Living Units
1
Actual Area
2,422 Sq.Ft
Living Area
2,044 Sq.Ft
Adjusted Area
2,227 Sq.Ft
Lot Size
9,225 Sq.Ft
Year Built
1949
Assessment Information
Year
2017
2016
2015
Land Value
$230,638
$198,007
$163,894
Building Value
$154,999
$154,999
$154,999
XF Value
$30,802
$31,164
$20,453
Market Value
$416,439
$384,170
$339,346
Assessed Value
$416,439
$384,170
$339,346
Benefits Information
Benefit
Type
2017 2016
2015
Note: Not all benefits are applicable to all Taxable Values (Le. County, School
Board, City, Regional).
Short Legal Description
DUNNINGS MIAMI SHORES EXT NO 3
PB 42-33
LOT 9 BLK 210
LOT SIZE 75.000 X 123
OR 19257-1926 06 2000 1
Generated On : 11/21/2017
Taxable Value Information
2017
2016
2015
County
Exemption Value
$0
$0
$0
Taxable Value
$416,439
$384,170
$339,346
School Board
Exemption Value
$0
$0
$0
Taxable Value
$416,439
$384,170
$339,346
City
Exemption Value
$0
$0
$0
Taxable Value
$416,439
$384,170
$339,346
Regional
Exemption Value $0 $0
$0
Taxable Value $416,439, $384,170
$339,346
Sales Information
Previous
OR
Sale
Price
Book-
Qualification Description
Page
03/12/2015
$359,100
29539-
Financial inst or "In Lieu of Forclosure"
2107
stated
07/29/2013
$100
28770 -Corrective,
0750
tax or QCD; min consideration
06/01/2000
$189,000
19257 -Sales
which are qualified
1926
04/01/1998
$0
18231-
Sales which are disqualified as a result of
4642
examination of the deed
The Office of the Property Appraiser is continually editing and updating the tax roll. This website may not reflect the most current information on record. The Property
Appraiser and Miami -Dade County assumes no liability, see full disclaimer and User Agreement at http://www.miamidade.gov/info/disclaimer.asp
Version:
11/21/2017 Detail by Entity Name
ClllYrto'1 vj3�
7 -7.or g t J it .i� a•
urs r. 1c! / ;tour Lf PI'/rl 1.14 i,
Department of State / Division of Corporations / Search Records / Detail By Document Number /
Detail by Entity Name
Florida Limited Liability Company
EAST WEST PROPERTIES HOLDING, LLC
Filing Information
Document Number L09000027055
FEI/EIN Number 90-0452327
Date Filed 03/19/2009
Effective Date 03/19/2009
State FL
Status ACTIVE
Principal Address
3900 NW 2ND AVENUE
Suite A
MIAMI, FL 33127
Changed: 04/04/2017
Mailing Address
3900 NW 2ND AVENUE
Suite A
MIAMI, FL 33127
Changed: 04/04/2017
Registered Agent Name & Address
STEADY MANAGEMENT, LLC
3900 NW 2ND AVE
Suite A
MIAMI, FL 33127
Name Changed: 03/15/2011
Address Changed: 04/04/2017
Authorized Person(s) Detail
Name & Address
Title Managing Member
STEADY MANAGEMENT, L.L.C.
3900 NW 2ND AVENUE
c. lit= n
http://search.sunbiz.org/Inquiry/CorporationSearch/SearchResultDetail?inquirytype=EntityName&directionType=Initial&searchNameOrder=EASTWESTPROP .. 1/2
11/21/2017
$yorg•
Detail by Entity Name
tuoOkla( .:d .t?%'Thrai& Leto
Department of State / Division of Corporations / Search Records / Detail 13,y Document Number /
Detail by Entity Name
Florida Limited Liability Company
STEADY MANAGEMENT, L.L.C.
Filing Information
Document Number L09000025849
FEI/EIN Number 61-1592847
Date Filed 03/16/2009
State FL
Status ACTIVE
Last Event LC AMENDMENT
Event Date Filed 12/20/2016
Event Effective Date NONE
Principal Address
3900 NW 2ND AVE
Suite A
MIAMI, FL 33127
Changed: 04/04/2017
Mailing Address
3900 NW 2ND AVE
Suite A
MIAMI, FL 33127
Changed: 04/04/2017
Registered Agent Name & Address
LEIDESDORF, EDMOND H
3900 NW 2ND AVE
Suite A
MIAMI, FL 33127
Name Changed: 02/01/2011
Address Changed: 04/04/2017
Authorized Person(s) Detail
Name & Address
Title MGR
http://search.sunbiz.org/Inquiry/CorporationSearch/SearchResultDetail?inquirytype=EntityName&directionType=Initial&searchNameOrder=STEADYMANAGE .. 1/2
11/21/2017
LEIDESDORF, EDMOND H
3900 NW 2ND AVENUE
Suite A
MIAMI, FL 33127
Title MGR
BROMLEY, STEPHEN
3900 NW 2ND AVE
Suite A
MIAMI, FL 33127
Annual Reports
Report Year Filed Date
2015 02/22/2015
2016 03/23/2016
2017 04/04/2017
Document Images
04/04/2017 — ANNUAL REPORT
12/20/2016 — LC 'Amendment
12/20/2016 -- CORLCDSMEM
03/23/2016 -- ANNUAL REPORT
02/22/2015 — ANNUAL REPORT
01/08/2014 — ANNUAL REPORT
08/2.2/2013 — LC Amendment
04/08/2013 — ANNUAL REPORT
01//23/2012 -- ANNUAL REPORT
02/01/2011 -- ANNUAL REPORT
01/08/2010 — ANNUAL REPORT
03/30/2009 -- Reg. Agent Change
03/16/2009 — Florida Limited Liability
View image in PDF format
Detail by Entity Name
View image in PDF format
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11/21/2017 Detail by Entity Name
../.J t/Li`-it
``FrIOi\.1
ray r jrc ttr .,t iit if Flue 'u :rite
Department of State / Division of Corporations / Search Records / Detail B...y Document Number /
Detail by Entity Name
Florida Limited Liability Company
STEADY MANAGEMENT, L.L.C.
Filing Information
Document Number L09000025849
FEI/EIN Number 61-1592847
Date Filed 03/16/2009
State FL
Status ACTIVE
Last Event LC AMENDMENT
Event Date Filed 12/20/2016
Event Effective Date NONE
Principal Address
3900 NW 2ND AVE
Suite A
MIAMI, FL 33127
Changed: 04/04/2017
Mailing Address
3900 NW 2ND AVE
Suite A
MIAMI, FL 33127
Changed: 04/04/2017
Registered Agent Name & Address
LEIDESDORF, EDMOND H
3900 NW 2ND AVE
Suite A
MIAMI, FL 33127
Name Changed: 02/01/2011
Address Changed: 04/04/2017
Authorized Person(s) Detail
Name & Address
Title MGR
http://search.sunbiz.org/Inquiry/CorporationSearch/SearchResultDetail?inquirytype=EntityName&directionType=Initial&searchNameOrder=STEADYMANAGE .. 1/2
Apr071504:23p Delta Insurance Und. Inc.
AC RD•
. • DATE (MMIDD/YYYY)
04/07/2015
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER,
3052691108
CERTIFICATE OF LIABILITY INSURANCE
p,1
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement A statement on thls certificate does not confer rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER
DELTA INSURANCE UNDERWRITERS, INC_
PHONE 305-269-1107
777 N.W. 72nd AVENUE, SUITE 3133 E -M No. EM):
MIAMI, FLORIDA33126
ADDRlESS; DELTAINSUND®AOL.COM
INSURED
CONTACT
NAME:
LUIS DE LA LLERA
No): 305-269-1109
ACA CONSTRUCTION, INC. dba ACA PLUMBING
10725 SW 55 TERRACE
MIAMI, FLORIDA 33165
INSURER(S) AFFORDING COVERAGE
INSURER A: ARCH SPECIALTY INSURANCE COMPANY
INSURER B:
NAIC k
21199
INSURER C:
INSURER 0:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:
REVIONBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORLTHE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDRIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
J TR ADDL SUER
INSR WVD
A
TYPE OF INSURANCE
GENERAL LIABILITY
7 COMMERCIAL GENERAL LIABILITY
JCLAJMSMADE 7 OCCUR
POLICY NUMBER
GENLAGGREGATE LIMTAPPLIES PER:
7 POLICY n ECTOJ- ;fl LOC
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED
AUTOS
HiREDAU70S
UMBRELLA LIAB
EXCESS UAB
SCHEDULED
IC] AUTOS
NON -OWNED
AUTOS
DED I I RETENTION $
OCCUR
CLAIMS -MADE
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
ANY PROPRI ETO R/PARTNEFLEXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH)
It yes, describe under
DESCRIPTION OF OPERATIONS below
Y/N
N1A
AGL003117-01
POLICYEFF
(MM)DDIYYYY)
08/05/2014
PULICY-EXP
(MMIDI Yyyy)
08/05/2015
EACH OCCURRENCE
LIMITS
RESE EaoEePRMES ( occurrence)
MED EXP (Any one person)
PERSONAL ADV INJURY
GENERAL AGGREGATE
PRODUCTS - COMP/OP AGG
Deductible per Claimant
COMBINED SJNG[E LIMIT
(Ea accident)
BODILY INJURY (Per person)
BODILY INJURY (Per accident)
PROPERTY DAMAGE
(Per accident)
EACH OCGURR=NCE
AGGREGATE
T T -I IOER
E.L. EACH ACCIDENT
EL OBEASE-EAEMPLDVEE
E.L. DISEASE - POUCY LIMIT
S
$
S
S
3
$
S
5
S
$
5
5
5
$
S
$
S
1,000,000.
100,000.
10,000.
1,000,000.
2,000,000.
1,000,000.
2,500.
DESCRIPTION OF OPERATIONS J LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
GENERAL CONTRACTOR LICENSE NUMBER: CGC1511172. PLUMBING CONTRACTOR LICENCE NUMBER: CFC1427635. ROOFING CONTRACTOR LICENSE
NUMBER: CCC1328217.
CERTIFICATE HOLDER
VILLAGE OF MIAMI SHORES / BUILDING DEPT.
10050 NE2nd AVENUE
MIAMI SHORES, FL 33138
PH 305 795 2204 FAX 305 756 8972
ACORD 25 (2010/05)
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
LUIS DE LA LLERA
10 ACORD CORPORATION. All rights reserved,
The ACORD name and logo are registered marks of ACORD
1
JEFF ArNATER
CIS FINANCIAL OFFICER
* CERTIFICATE OF EL.E4
CONN U 11ON INDUS -MY EXEM
This certifies that the individual fisted betaw e4ected It3 eySempt from Florida Workers' Der v, law.
[ TO BE
FROM FLORIDA WORKERS' C
�#PE;
EFFECTN'E DATE: 6/19/2014
RSON: LEMUS
204524410
BUSINESS NAME AND ADDRESS:
ACA CONSTRUCTION INC
EXPIRATION DATE: 5118/2016
FL
SCOPES OF BUSINESS OR TRADE:
LICENSED GENERAL
CONTRACTOR
LICENSED PLUMBING
CONTRACTOR
LICENSED ROORNG
CONTRACTOR
Pursuant to Crispier 44.1.05(14), F.S.. en officer of it c orporsibn who tom ills chapter by fi+rug a vus Aosta of election order %ie section..-.
net recover benefits or care on under tee. callow, Pursuant to Chiseler 44t►i 5 12), F s., Cartiftcases of ete:eon tc te exempt... apply only even the susx
of the txsineea or trade fated on hi rorka of riecion to bo .z rrgL Pursuant to Chapter 444.050 3), F.S., 40fica4 c diKtoo to to eacm * ant uerdcatts ^'
erection b be exempt fiat be sutalect to revocation 4, at any time otter the %no of Me notice or the issuance of the cx rtcticate, CRe per era named on the loam a.
cargficste no meets the rer urernents of true *crease for Issuance of e certificate. The department she res e a cerufraae al any rote trx tams. 4! ate
person named an rte oar caTc tc mae the rsqueremortt of thb 'Acton..
Sep 10 1501:58p Delta Insurance Und. Inc.
3052691108
p.1
'4 - ' CERTIFICATE OF LIABILITY INSURANCE
DATE(YYYY)
os110/20arzo15
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. 11 SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER
INSURANCE UNDERWRITERS, INC.
777 N.W. 72nd AVENUE, SUITE 3133
MIAMI, FLORIDA 33126
CONCT LUIS DE LA LLERA
NADELTA
PHONE 305-269-1107 JF 305-269-1108
AlC No, Est): N , Nol:
E--MAILLSS: DELTAINSUNDOA0L.COM
INSURERS) AFFORDING COVERAGE
MAIC t
INSURER A: ARCH SPECIALTY INSURANCE COMPANY
21199
INSURED
ACA CONSTRUCTION, INC. dba ACA PLUMBING
10725 SW 55 TERRACE
MIAMI, FLORIDA33165
INSURER B:
INSURER C:
INSURER D:
_
$ 1,000,000.
INSURER E:
V9
INSURER F:
CERTIFICATE NUMBER•
THIS 15 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDINGANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED 8Y THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR
TYPE OF INSURANCE
INSRSR
WVD
POLICY NUMBER
PMIDDI YT
fMM/DlM'YYY)
TEXP
FM1D /W
(MMlDWYYYYI
LIMITS
GENERAL
LIABILITY
COMMERCIAL
EACH OCCURRENCE
_
$ 1,000,000.
V9
GENERAL LIABILITY
DAMAGE TO RENTED
100,000.
PREMISES (Ea occurrence)
s
CLAIMS -MADE IVI OCCUR
MED
10,000.
EXP (My one person)
$
A
AGL003117-02
08/05/2015
08/05/2016
PERSONAL
1,000,000.
—
AADV INJURY
s
GENERAL
2,000,000.
AGGREGATE
$
GEN'LAGGREGATE LINITAPPLIESPER:
PEW-
PRODUCTS -COMP/OPAGG
$ 1,000,000.
1 POUCY [1 FT LOC
Deductible per Claimant
$ 2,500.
AUTOMOBILE
LIABILITY
L'0Ml )NED� SINGLE LIMIT
(Ea 17074
$
--ALL
ANYAUTO
OWNEC
--SCHEDULED
BODILY INJURY (Per person)
S
At1TOSAUTOS
HIRED AUTOS
—
NON -OWNED
BODILY fNJURY (Per accident)
$
AUTOS
(Pe den7)DAA4AGE
$
$
—
UMBRELLA LIAB
I
jl
I OCCUR
EACH OCCURRENCE
$
EXCESS LIAB
I
CLAIMS -MADE
AGGREGATE
$
DED I RETENTION $
$
WORKERS COMPENSATION ANDWC
EMPLOYERS' LIABIUTY y/ N
STAID- OTH-
I TORY LIMITS I ER
ANY PROPRIETOR/FARMER/EXECUTIVE
OFFlCER/MEMBEREXCLUDED7
NIA
E.LEACH ACCIDENT
$
(Mandatory In NH)
It yes, des 1be under
EL DISEASE- EAEUPLOYEE
S
DESCRIPTION OF OPERATIONS below
EL DISEASE - POLICY LIMIT
S
DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required)
GENERAL CONTRACTOR LICENSE NUMBER: CGC1511172. PLUMBING CONTRACTOR LICENCE NUMBER: CFC1427635. ROOFING CONTRACTOR LICENSE
NUMBER: CCC1328217.
CERTIFICATE HOLDER .....—..._.___
VILLAGE OF MIAMI SHORES / BUILDING DEPT.
10050 NE 2nd AVENUE
MIAMI SHORES, FL 33138
PH 305 795 2204 FAX 305 756 8972
ACORD 25 (2010105)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
LUIS DE LA LLERA
@ 1988-2010 ACORD CORPORATION. All rights reserve1
d.
The ACORD name and logo are registered marks of ACORD
ACA CONSTRUCTION, INC
10425 SW 55 TER
MIAMI, FL 33165
September 14th, 2015
Miami Shores Village
'.0050 NE 2nd Avenue
Miami Shores, FL 33138
State of: Florida
County of: Dade
Before me this day, personally appeared Andres Lemus who, being duly sworn, deposes and says:
That he will be the only person working on the project located at 5 NE 107 Street Miami Shores, FL
33138.
Sworn to me (or affirmed) and subscribed before me this 14th day of September, 2015, by " res Lemus
Personally known V
OR Produced Identification
Type of Identification Produced
Print, Type, or Stamp Name of Notary
Ip
r.ir►+`iNI AN i3 BLANK
• MY COMMISSION #FF158014
Ott ! 8Y 'tE8 October 1, 2018
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Notice to Owner — Workers' Compensation Insurance Exemption
Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05
allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to
obtaining a building permit. Pursuant to the Florida Division of Workers' Compensation Employer Facts Brochure:
An employer in the construction industry who employs one or more part-time or full-time
employees, including the owner, must obtain workers' compensation coverage. Corporate officers
or members of a limited liability company (LLC) in the construction industry may elect to be
exempt if:
1. The officer owns at least 10 percent of the stock of the corporation, or in the case of
an LLC, a statement attesting to the minimum 10 percent ownership;
2. The officer is listed as an officer of the corporation in the records of the Florida
Department of State, Division of Corporations; and
3. The corporation is registered and listed as active with the Florida Department of
State, Division of Corporations.
No more than three corporate officers per corporation or limited liability company members are
allowed to be exempt. Construction exemptions are valid for a period of two years or until a
voluntary revocation is filed or the exemption is revoked by the Division.
Your contractor is requesting a permit under this workers' compensation exemption and has acknowledge that he or she will not use
day labor, part-time employees or subcontractors for your project. The contractor has provided an affidavit stating that he or she will
be the only person allowed to work on your project. In these circumstances, Miami Shores Village does not require verification of
workers' compensation insurance coverage from the contractor's company for day labor, part-time employees or subcontractors.
BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Signature:
State of Florida
County of Miami -Dade
The foregoing was acknowledge before me this 1 rttay of
By Ll:� - c-�C�-PjcI,( Q who isp
as identification.
Notary:
SEAL:
rsonally kno
,2015..
to me or has produced
RONNI ANN BL ANC
' :AIM M i -> N- BLANK . ���, MY COMMISSION #FF15 14
1' EXPIRES October 1, 2018
,t.«�' COMMISSION NFF158014 '•.,,►,orn;,..:� ?'- ryService.wm
0S tlClober 1, 2018 4o7f 398.0153 Fwridallota
i , :.,1,2‘,:i LhiyService.com
SLD
,' j A.S.D. Consulting Engineers, Inc
17320 SW 142"° PL
Miami Fl 33177
Ph: (786) 351 3663
Fax: (786) 478 6950
TO: Building Department Official
FROM: Fernando Azcue, P.E, SI.
Structural Engineer, FL Reg. No. 65521
DATE: November 9t1', 2015
RE: Window Buck Inspection
5 NE 107T" STREET
MIAMI SHORES, FLORIDA 33138
�c
/6-- s'6y
Building Department Official
Our firm has been retained to perform the Window Buck Inspection for the above mentioned
project.
As per our inspection, the buck installation is properly attached to the substrate. All Bucks
are in compliance with the strength requirements of the 2014 Florida Building Code.
"As a routine matter, in order to avoid possible misunderstanding, nothing in this
report should be construed directly or indirectly as a guarantee for any portion of the
structure. To the best of my knowledge and ability, this report represents an accurate
appraisal of the present condition of the "inspected part of the building" based upon
careful evaluation of observed conditions, to the extent reasonably possible. There was
no destructive testing done at the previously addressed."
Should you have any questions or need any additional information, please do not hesitate to
contact me.
Sincerely,
ernan.. zcue, P.E.
Lic. ,1• • 5521
S.I. No. 7023770